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ip <br /> � / SAN JOAQUIN COUNTY <br /> vENVIRONMENTAL HEALTH DEPARTMENT1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone:(209) 468-3420 Fax: (209)468-3433 Web:www.sigov.org/ehd <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> 0s-o�) - <br /> Facility Ad re : Service Request#: <br /> 32 l,ar► <br /> Onsite Service Technician'sName: ICC Service Tech ciaNlnstaller Exp.Date: Manu c r ai ing: <br /> 3 <br /> SERVICE SERVICE <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> ❑ ❑ mechanical Model: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial#: ❑ Caldwell System ❑ Other <br /> ❑ line test programmed <br /> _Leak detector Spill bucket ❑ minimum 5 gallon <br /> ❑ mechanical Model: <br /> El El electronic Serial#: El 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test ro rammed ❑ Caldwell System ❑ Other <br /> sensor Primary piping testing at: <br /> ❑ ❑ positive shutdown Model: El _psi <br /> El fail safe Serial#: minutes <br /> ❑ NA <br /> sensor Secondary containment testing for: <br /> ❑ ❑ positive shutdown Model: UDC(s) Piping <br /> ❑ fail safe Serial#: Sump(s) UST(s) <br /> ❑ NA <br /> sensor ❑ Testing for the above components are next due by: <br /> ElElpositive shutdown Model: <br /> ❑ fall safe Serial#: Note: Please be aware that 2 containment components are required to be tested upon <br /> ❑ NA installation,6 months after,and every 36 months thereafter. <br /> ❑ Drop tube with mechanical overfill at 95% ❑ Cold start of monitoring panel <br /> ❑ Drop tube with mechanical overfill at 95% ❑ Corrosion protection <br /> ❑ Overfill prevention (see LG letter 150-1) ❑f Other: <br /> see below <br /> El This UST facility is APPROVED to operate EI -�kis�UST fee*'*jr is NOT APPROVED to operate <br /> 4,jjc�ud ft a- AA14004M -114v III <br /> 44 AAJ <br /> ! . r <br /> 111`11-119 FAcil-try IS SUBJECT TO REINSPECTION AT ANY TIM T EHD'S CURRENT HOURLY RATE. <br /> EHD IReceived By: - Title: 1y� <br /> INS r \ec <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4130/12 <br />